The Transosseous Internal Four Strand Technique: A New All-Inside Technique for Zone 1 Flexor Tendon Repairs.

BACKGROUND: Multiple techniques for the repair of flexor tendon injuries in zone 1 have been proposed over time. While pull-out suture techniques and bone anchor seem to be stronger than internal suture techniques, they are associated with a higher complication rate. We therefore developed an alternative internal suture repair with similar biomechanical stability to those of pull-out sutures and bone anchors. METHODS: Twenty porcine distal phalanges and deep flexor tendons were randomized to 2 groups of 10 each. The tendons were transsected at the level of the distal interphalangeal joint. In group 1, repairs were performed with a well-established intraosseous suture repair and in group 2 with our new multistrand technique. The repairs were biomechanically tested with linear distraction until failure. RESULTS: We recorded a significantly higher 2-mm gap force (2GF)-and thus higher stability-of the repairs in group 1 in comparison to group 2. With a 2GF of more than 50 N, our suture technique allows for a modern early active motion rehabilitation protocol. Breakage of the suture construct occurred at random places in the repair in both groups. No pull-outs were noted. CONCLUSIONS: This study presents a strong transosseous multistrand repair technique for flexor tendon repair in zone 1 that is simple and fast to perform and should have enough strength to withstand early active motion rehabilitation.

Transosseous Sutures in Tendon-to-Bone Repairs: the Role of the Epitendinous Suture.

BACKGROUND: Numerous transosseous fixation techniques for flexor tendon injuries in Zone 1 of the hand have been described in the literature. While relatively high maximal loads to failure are documented in different biomechanical experiments, several tests revealed a low 2 mm gapping resistance of the tendon-to-bone repairs. We therefore aimed to investigate the effect on gap formation adding a peripheral suture to an established transosseous fixation technique. In addition, we analyzed the influence of different suture materials (braided vs. non-braided) on the stability of the core suture. METHOD: A total of 30 porcine flexor digitorum profundus tendons were divided into 3 groups (n = 10 each) and repaired using the transverse intraosseous loop technique (TILT). In group 1 and group 2 the repairs were performed using PDS 3-0 or Ethibond 3-0, respectively. In group 3, a peripheral suture was added to the core suture (PDS 3-0) consisting of two figure-of-eight stitches with PDS 5-0. The biomechanical performance of the repaired tendons was analyzed using a standardized protocol. RESULTS: The suture material and peripheral suture showed no effect on the ultimate failure load in our testing. However, the addition of a peripheral suture led to a statistically significantly higher 2 mm gap force when compared with the repair with a core suture only. CONCLUSION: In conclusion, addition of a palmar epitendinous suture to the transosseous core suture significantly increases the load to 2 mm gap formation in Zone 1 flexor tendon repairs and thus allows an immediate controlled mobilization.

CASE REPORT Febrile Ulceronecrotic Mucha-Habermann Disease.

OBJECTIVE: Case report and review of the current literature about febrile ulceronecrotic Mucha-Habermann disease (FUMHD). METHODS: Review of our patient's medical records and of the current literature. RESULTS: The FUMHD is a rare and potentially lethal type of pityriasis lichenoides et varioliformis acuta. It is characterized by the sudden onset of ulceronecrotic skin lesions associated with high fever and systemic symptoms. Because of a high case-fatality rate it requires quick and decisive action. Only 40 cases of this severe form of the disease have been reported in the literature to date. We present the case of a 30-year-old male patient with severe FUMHD who was successfully treated in our burn intensive care unit after failed treatment at a dermatological hospital. The patient was treated with topical antiseptics, moisturizers, and artificial skin substitutes, as well as systemic immunosuppressive therapy (glucocorticoids) with which we were able to control the disease activity so that healing of the patient's skin lesions could be achieved. CONCLUSION: Patients with FUMHD should be treated in a specialized center for severely burned patients. Only such centers can provide the structural and logistical capacities necessary for the treatment of such extensive superficial wounds.

Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects.

OBJECTIVE: In some patients with chest wall defects, free tissue transfer is indicated. Complications arise if multiple operations have left the trunk devoid of recipient vessels. In such patients, an arteriovenous loop between the cephalic vein and the thoracoacromial artery can be used. METHODS: A review of all our patients who underwent chest wall reconstruction with a cephalic vein-thoracoacromial artery loop between 2000 and 2009 was performed (n = 29, 19 women and 10 men). The mean age was 64.9 years. Underlying causes were sternal osteomyelitis (n = 20), tumor (n = 4), and osteoradionecrosis (n = 5). All patients were in American Society of Anesthesiologists classes III and IV. Flap selection, intraoperative and postoperative complications, operative time, time of ventilatory support, mean hospital stay, and midterm survival were recorded. RESULTS: Twenty-five patients received a tensor fascia lata flap, 2 a vertical rectus myocutaneuos flap, and 2 a deep inferior epigastric perforator flap. Mean duration of surgery was 6.8 hours (4.7-10.5 hours). Two transplanted tissue flaps died and/or had to be removed and 4 were revised successfully. Seven patients had wound complications such as infection or prolonged wound healing. Mean time for ventilator support was 93.6 hours (4-463 hours). The median intensive care unit time was 11 days and the overall hospital stay 27.4 days (11-102 days). One-year survival in the whole group was 69.8%. CONCLUSIONS: The concept of arteriovenous loops allows creation of neovessels at the recipient site and has proven to be a superb tool to facilitate free tissue transfer or to provide an exit strategy in situations with unexpected vascular problems at the recipient site.

Total scapholunate dislocation with complete scaphoid extrusion: case report.

A case of complete dislocation of the lunate and scaphoid resulting from a fall is reported. We are unaware of any previously reported case of simultaneous dislocation with the scaphoid completely extruded from the wrist at the time of injury. The patient was treated with a proximal row carpectomy.